Your Brain Doesn’t Need More Puzzles: A Call to Action for Real Dementia Prevention in Palliative Care

For years, popular advice about preventing dementia has centered on the idea that brain games—crossword puzzles, Sudoku, language apps—can preserve cognition and slow decline. But what if this advice is not only misguided, but actively harmful? What if it offers patients and families false reassurance, while the root causes of cognitive deterioration go unaddressed?

As palliative care professionals, we are uniquely positioned to reshape the narrative. We see what happens when the warning signs are missed or ignored. We witness the compounded suffering that results from untreated comorbidities. And yet, we often encounter patients—and families—who proudly tout their 500-day streak in a brain training app, even as untreated sleep apnea, unmanaged hypertension, and unused hearing aids quietly erode their brain health.

We are playing games while the brain suffocates at night.

Let’s unpack why our current dementia prevention advice isn’t working—and what truly makes a difference.

The Crossword Fallacy

Cognitive training can improve performance on specific tasks. Doing crosswords makes you better at doing crosswords. But there is no convincing evidence that these tasks lead to meaningful improvements in real-world cognition, functional independence, or delayed dementia onset. The brain adapts to specific tasks—it doesn’t generalize that skill to managing medications, paying bills, or navigating new environments.

Worse, the illusion of protection creates false security. Patients assume they’re doing “what they can,” while modifiable, evidence-based risks are ignored.

The Overlooked Risk Factors

True dementia prevention is neither flashy nor lucrative. It doesn’t live in an app store. It lives in our exam rooms and living rooms, often hidden in plain sight:

• Untreated Hearing Loss: Hearing impairment in midlife is one of the largest modifiable risk factors for dementia. Treating hearing loss reduces dementia risk by up to 18%. Yet hearing aids often sit unused in drawers.
• Sleep Apnea: Chronic nocturnal hypoxia is profoundly neurotoxic. Untreated obstructive sleep apnea deprives the brain of oxygen, disrupts sleep architecture, and accelerates cognitive decline. Diagnosing and aggressively managing sleep apnea is essential.
• Hypertension: Midlife blood pressure control is one of the most powerful tools in our prevention arsenal. Vascular contributions to cognitive impairment and dementia (VCID) are common and treatable.
• Social Isolation: Social engagement isn't a luxury—it’s a neural necessity. Isolation increases risk for depression, cognitive decline, and premature mortality. Relationships—not Facebook connections, but genuine, in-person relationships—protect cognition.

These aren’t fringe interventions. They’re foundational. But because they’re not marketed with sleek graphics and catchy slogans, they get ignored.

The Power of Physical Activity

Exercise is the most effective cognitive enhancer we have. Regular physical activity:

• Increases BDNF (Brain-Derived Neurotrophic Factor), which supports neuronal growth and plasticity
• Enhances vascular health, improving cerebral perfusion
• Reduces systemic inflammation, a known contributor to neurodegeneration
• Literally increases hippocampal volume—one of the first regions affected in Alzheimer’s disease

Nothing else—no puzzle, app, or pill—matches exercise in its broad and sustained benefits to the aging brain.

The Prevention Paradox

What works is boring. What doesn’t work is marketable. That’s the paradox. Apps sell because they promise a shortcut. But brain health doesn’t come in shortcuts. It comes from lifestyle changes that feel mundane and effortful—but work.

As clinicians, we must lead with clarity and courage. We must stop co-signing ineffective advice and start advocating for what matters most.

A Clinical Call to Action

Next time you see a patient with cognitive concerns, look beyond puzzles and apps. Ask about their sleep. Screen for hearing loss. Review blood pressure history. Encourage movement and human connection. Reinforce that brain health depends not just on neurons—but on oxygen, circulation, and engagement.

Tell families the truth: your brain doesn’t need more puzzles. It needs oxygen, blood flow, and connection.

And when someone offers them a subscription to the latest brain game, teach them to ask one simple question: “What did your sleep study show?”

References:

Livingston, Gill et al. Dementia prevention, intervention, and care: 2020 report of the Lancet Commission. The Lancet, Volume 396, Issue 10248, 413 - 446.

Yaffe K, Laffan AM, Harrison SL, et al. Sleep-Disordered Breathing, Hypoxia, and Risk of Mild Cognitive Impairment and Dementia in Older Women. JAMA. 2011;306(6):613–619.

Leng Y, McEvoy CT, Allen IE, Yaffe K. Association of Sleep-Disordered Breathing With Cognitive Function and Risk of Cognitive Impairment: A Systematic Review and Meta-analysis . JAMA Neurol. 2017;74(10):1237–1245.

K.I. Erickson, M.W. Voss, R.S. Prakash, C. Basak, A. Szabo, L. Chaddock, J.S. Kim, S. Heo, H. Alves, S.M. White, T.R. Wojcicki, E. Mailey, V.J. Vieira, S.A. Martin, B.D. Pence, J.A. Woods, E. McAuley, & A.F. Kramer, Exercise training increases size of hippocampus and improves memory, Proc. Natl. Acad. Sci. U.S.A. 108 (7) 3017-3022.

Ahlskog, J. Eric et al. Physical Exercise as a Preventive or Disease-Modifying Treatment of Dementia and Brain Aging. Mayo Clinic Proceedings, Volume 86, Issue 9, 876 - 884.

Walker, K.A., Power, M.C. & Gottesman, R.F. Defining the Relationship Between Hypertension, Cognitive Decline, and Dementia: a Review. Curr Hypertens Rep 19, 24 (2017).

Donovan NJ, Okereke OI, Vannini P, et al. Association of Higher Cortical Amyloid Burden With Loneliness in Cognitively Normal Older Adults. JAMA Psychiatry. 2016;73(12):1230–1237. 

Simons, D. J., Boot, W. R., Charness, N., Gathercole, S. E., Chabris, C. F., Hambrick, D. Z., & Stine-Morrow, E. A. L. (2016). Do “Brain-Training” Programs Work? Psychological Science in the Public Interest, 17(3), 103-186.

Owen, A., Hampshire, A., Grahn, J. et al. Putting brain training to the test. Nature 465, 775–778 (2010).